Please note: questions indicated by * are mandatory fields

    Your Title:

    MrMsMrsProfOther

    Given Name *

    Last Name *

    Middle Names

    Date of Birth*

    Telephone (Mobile)*

    Email Address *

    Residential Address *

    Do you have a current GP referral ?*
    YesNoNot yet but will get one
    You can upload your GP referral now or bring it with you on the day.

    Referring GP's name?

    Referring GP's practice?

    Do you have Medicare?*
    YesNo

    Medicare Number

    Reference Number (number that appears before your name on your medicare card)

    Do you have a Department of Veteran Affairs (DVA) card?*
    YesNo

    Do you have private health insurance?*
    YesNo

    Health Insurance Name

    Health Insurance Number

    What is the reason for having the gastroscopy?*
    Reflux symtpoms or HeartburnAbdominal BloatingPrevious Gastric UlcersPrevious Helicobactor Pylori InfectionAnaemia (low haemoglobin or low iron)Barrett's OesophagusPrevious Upper Gastrointestinal CancerFamily history of stomach, oesophagus or duodenal cancerStomach (Abdominal) Pain or BloatingOther

    Preferred date for procedure (Monday to Friday only)

    Preferred hospital for procedure

    North Shore Specialist Day HospitalWestmead Private HospitalFirst available

    Preferred Surgeon

    Dr Barry McCabeDr Maroof KhanDr Sebastian RodriguesFirst Available

    Please select if you are on any of the following blood-thinner medications?
    AspirinClexaneCalciparinClopidogrelCoumadinEliquisIscoverPradaxaWarfarinXareltoOther

    Please select if you are on any of the following diabetic medications?
    DiaforminDiamicronForxigaGlucobayInvokanaJardianceMetforminInsulinOther

    Please select if you have any of the following medical conditions?
    Cardiac StentCardiac DiseasePrevious Heart AttackKidney FailureLiver ConditionEpilepsyLung Disease

    Please also feel free to add any additional comments here.

    Consent to release medical information
    I give my consent to Endoscopy Online, or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Endoscopy Online, or their agents and advisors, as may be requested. This is in line with the National Privacy Act. By selecting the box below you agree to these terms and conditions.

    Yes, I have read and consent to the above terms and conditions. *

    Yes, I have read the relevant information on Direct Access Gastroscopy including risks and complications.*